St Gallen Colorectal Consensus Expert Group publish paper on TaTME

The paper strongly recommended proper training, including participation in dedicated courses and proctoring of the first cases before embarking on independent practice of TaTME

The St Gallen Colorectal Consensus Expert Group, consisting of 37 colorectal surgeons from 20 countries and five continents (Europe, Asia, North and South America, Australasia) and a radiologist, pathologist and medical oncologist, have published a broad international consensus statement for the optimal practice of transanal total mesorectal excision (TaTME). The statement provides guidance on the safe implementation of, and how to avoid the pitfalls and potential major morbidity encountered by, the procedure. The consensus paper, ‘St Gallen consensus on safe implementation of transanal total mesorectal excision’, was published in Surgical Endoscopy.

The objectives of the consensus statement are:

to provide a framework and guidance to those embarking on TaTME, including patient selection and surgical indication, technique, and educational opportunities;

to highlight the challenges, benefits, and distinctive dangers of this technique, capitalizing on a large international experience of early adopters of TaTME; and

to promote prospective outcomes analysis and participation into clinical trials and registries.

The experts had performed at least 20 TaTME cases and have reported their results in peer-reviewed publications and registries. The consensus statements were developed using Delphi methodology incorporating three successive rounds and consensus was defined as agreement by 80% or more of the experts.

Specifically, the Expert Group focused on seven key areas:

patient selection and surgical indication

perioperative management

patient positioning and operating room set up

surgical technique, devices and instruments

pelvic anatomy

TaTME training; and

outcomes analysis

The consensus statements achieved more than 80% approval for most of these areas, which were graded as strong recommendations. However, the paper acknowledges that there is a current lack of high-level evidence in support of this recommendation, which is based only on expert opinion. On the other hand, the panel of experts found a large agreement on all the different questions.

The paper strongly recommended proper training, including participation in dedicated courses and proctoring of the first cases before embarking on independent practice of TaTME. In addition, it was agreed that a minimum learning curve of 20 cases performed within about two years was deeded ‘reasonable’, although individual variability may influence the length and steepness of the learning curve. The paper encouraged participation with an international registry and/or clinical to share experience and benchmark one’s practice with other surgeons and institutions.

“This multidisciplinary consensus statement achieved more than 80% approval and can thus be graded as strong recommendation, yet acknowledging the current lack of high level evidence,” the authors concluded. “It provides the best possible guidance for safe implementation and practice of Transanal Total Mesorectal Excision.”